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Thursday, June 21, 2012

About a year ago, I was having lunch with a friend when the
subject of finding a good doctor came up. What makes a good doctor?
What qualities are most valued? My friend leaned forward and asserted, “I
really don’t care if my doctor is nice and all that stuff, I just want the
freakin’ smartest doctor I can find.” I pressed my lips into a
half-smile. I didn’t agree with her at the time, but I found my ability
to counter lodged somewhere between my heart and my throat. The truth is,
when I started medical school, I felt much the same way. Who cares if a
doc pats you on the shoulder and comforts you? Who cares if she smiles
and asks you about your wife, kids, and pet zebrafish? To me, all this
was much like the toy that comes with your kid’s meal—a delightful bonus, but
not the real substance of medicine. I just wanted someone to do the right
tests, give me the right meds, and send me on my way—fixed up and ready to
go. But even in the first few months of my training, I could see that my
initial impression of good medicine was rather short-sighted. It seemed
odd that on one hand, I was a proud member of a fraternity that prides itself
on stratospheric test scores and intellectual acrobatics. Yet on the other
hand, I was beginning to see that brute intellect plays only a small supporting
role in medicine’s celebrated script. For many of us, this comes as a
hard pill to swallow. But the truth is it doesn’t take a genius to be a
great doctor.

Part of the problem for both patients and providers alike is that
we often view illness as a technical difficulty. If our computer crashes, we
expect the whiz at Apple to uncover the problem and provide the restorative
reboot. If our car crashes, find us a skilled mechanic who can dive under
the hood and give it new life. Hell, if the economy crashes, we believe
the officials we elect to office should have the power to tweak a few policies,
rejigger the interest rate, and get our GDP rocketing skyward again. And
why not? We are of a bold generation that has always viewed even the most
complex problems as a giant brain away from happy resolution. But what if
a loved one gets sick? And what if it’s my child—not my computer—who’s
crashing? Often, our initial intuition is the same. Employ
the smartest doctor in the hospital to swap a few meds, execute some elaborate
surgery, and restore everything back to normal. A doctor’s job is to fix
our cracks and mend our leaks so we can get on with our lives. And presumably,
the smartest ones are also the best fixers. But of course, matters of
life—and death—are never quite so simple.

Despite whatever value we assign to our beloved gadgets, laptops
don’t think, and cars don’t feel. They also don’t dream, aspire, believe,
defy, invent, or imagine. It’s the fingers that touch a keyboard that
possess the ability to translate the ideas and emotions of a brazen mind.
Cars carry passengers, but it’s the passengers who carry a lifetime of joys and
sorrows. And when an economy crashes, it’s the people who suffer, not the
GDP. So while flawed devices and failed policies can be restored and
renewed, they can also be discarded. Human beings—well, not so
much. This is the real grit of medicine. We can preserve health, but
not indefinitely. We can treat pain, but we don’t cure misery.
Despite all our medical advances, more often than not, our job is not to
fix, but to advise, to advocate, and to comfort when suffering has already
established a foothold. The brilliant engineer must decipher when old
parts should be abandoned and outdated systems replaced. The great
physician—she must walk with the worn, and sit with the broken. And it’s
not that we should disregard the breadth of her knowledge. It’s just that
there is truly no replacement for the depth of her compassion.

For those of us who still view illness as technical blip, it’s
likely because we have never been truly sick or cared for the gravely
ill. Yes, we’ve probably taken antibiotics for a throat infection or
received x-rays for a broken bone. Maybe even gone through surgery and
rehab for certain injuries. But the most common and costly diseases
afflicting Americans are the unsexy, life-sapping diagnoses that prompt years,
even decades, of suffering. Diabetes, depression, heart disease,
cancer—all chronic diseases without cure. If you spend enough time around
doctors, you will hear them refer to treatment as “medical management.”
Because in cases of long-standing illness, it isn’t about coming up with
dazzling answers or pondering over a mysterious case until reaching that single
“aha!” moment. You work with patients to juggle a dozen prescription pill
bottles. You remind patients why they can’t eat their favorite foods—the
ones they’ve grown up enjoying. You even prepare patients for how
chemotherapy will cause them to lose their hair, their hearing, their sex
drive, and much of their independence. And you help them understand why
once your health leaves you, it doesn’t often come back. Because
for patients whose lives are marred by poor health, medicine becomes more about
dedicated support, compassionate care, and constant education. It turns
out the ability to perform high-flying mental acrobatics is really just a
bonus. Like that toy that comes with your kiddy meal. When you are
truly famished, your focus shouldn’t be on the toy.

The truth is that for many patients, they come to a doctor sick,
and leave sick. And for 365 days a year, they are the ones taking care of
themselves. Physicians don’t get to play miracle healer as often as
they’d like. Instead, the challenge is how to better empower patients to
choose for themselves the lives they want to live, even when illness has become
a part of everyday reality. I know if someone I really cared about got sick,
there are some people in my class I would trust without hesitation. Not
because they are brilliant, though most of them are. But because they are
the type of people that you can trust to carefully guide you while
understanding that your diagnosis is not your defining characteristic.
For those who are truly ill, there are often many tough decisions with few good
outcomes. And the “right” decision is different for each
individual. Because after all, we aren’t just a collection of moving
parts, all mass-produced from the same mold. We harbor unique thoughts,
values, and aspirations. And all of these things play into excellent
care. Clearly, amputating a pinky finger might mean one thing to me, and
something very different to a concert pianist. Simply put, there are
“good” answers, and then there is true guidance. The latter is what
distinguishes the outstanding physician. It may not require the gift of
pure genius, but it demands a level of human compassion that is perhaps every
bit as rare.

Thursday, June 7, 2012

“It doesn’t have to look
pretty,” my resident grinned as he slipped out of the room, pass the sliding
glass doors. I looked up from the
half-tied knot that was securing the gown to my waist. “Alright,” I nodded. Around me, the whirlwind of alarms that compliments
most ICU beds had ceased. I lifted a
needle holder off my patient’s lap, grabbed the needle that had been laid out
for me, and loaded it. The room was now
dim, aside from the lamp that hovered at arm’s length above me. It draped white over my shoulder and onto the
wound I was prepared to close. My gaze
slid along the serrated fibers of muscle which framed a crude window cut
between two ribs. There, through the
gaping slit in this man’s side, a piece of the lung stared out at me. And at the top corner of this window, just
beneath the breastplate, a fleshy corner of his heart peered out as well. I lowered metal to flesh and watched the
needle take its first bite. His body was
still warm.

Wednesday 9:12 p.m. My trauma pager had gone off. Instinctively, I squelched its beeping, shuffled
to the nearest elevator, and descended down to the emergency room. There, I met up with the rest of my team and
listened as a nurse on the phone provided updates. A patient had been found down by the side of
the freeway. He was en route by
helicopter. We stationed ourselves
around the designated room, waited, and made small talk. Fifteen minutes went by. Then a pale, unresponsive man was wheeled
into the trauma bay with a medic crouched above him performing CPR. “This is a thirty-year-old John Doe… jumped
out of a vehicle moving at highway speeds… unresponsive with agonal breathing
when first responders arrived… heart stopped beating in transport.” As the medic gave his report, a curtain of
providers descended in a synchronized flurry upon the patient. From my position at the edge of the room, I
watched as the trauma resident grabbed a scalpel, sliced open the chest, swept
the lung aside, and began compressing the heart. The patient’s intrinsic heartbeat returned
and within seconds, we were in an elevator on our way to the operating room.

I could hear the steady rhythm
of my breaths cycling beneath my facemask.
It was punctuated momentarily by the click of my needle holder as it
seized the metal tip at the surface of the skin. I pulled another stitch through, gave it a
tug, and felt the thread bite into my palm.
Slowly, the edges of the wound began to ease together. Across the man’s chest, the suture spiraled
silver—diving in and out, back and forth, from the breastplate to just beneath
the nipple before jumping off the skin and onto the needle at the end of my
instrument. The rest of the wound stood
open from this point. It widened
underneath the armpit before tapering back down to a corner where the patient’s
frame rested against the bed. I looked
at the half that remained open, re-angled the light above me, and continued
working.

A bead of sweat dripped down
the side of my cheek and dissolved into my facemask. I fastened one last knot, cut the remaining
suture, and set my instruments down.
With a damp cloth, I wiped the dried blood off the newly closed
wound. I stepped out from underneath the
lamp light and glanced at the closure.
The suture that held the incision together resembled the seam of a
baseball, only knotted within the flesh of this man’s chest. In some ways, it looked every bit as unnatural
as when it lied open with organs visible between flaps of skin and tissue. I turned toward the door, shed the protective
layering I had on, and stepped back into the heart of the ICU. My resident looked up from his seat. “I’m done,” I informed him.

Thursday 12:53 a.m. I propped
myself on a step by the patient’s chest.
He had made it through surgery only to have his heart stop twenty
minutes after arriving in the ICU. My
resident was calling out orders from his position at the bedside as nurses
zipped in and out of the room. I could
hear the practiced calm in his voice.
“Alright, take over,” he instructed, stepping away from the bed while
continuing to run the code. I began
chest compressions. Our attending surgeon
slipped into the room, exchanged a few words with the resident, and moved to
re-open the patient’s chest. I took my
hands off the breastplate. Reaching for
the lamp above me, I focused it on the thoracotomy. The attending cut the sutures, spread the ribs
apart and reached in. A nurse handed him
a small paddle connected to a defibrillator.
He positioned it on the heart’s surface and everyone stepped away from
the bed. A shock was delivered. Nothing.
The attending stuck his hand back in the chest and resumed cardiac
compressions. After two minutes, we
tried the defibrillator again, followed again by internal CPR. Still nothing. “Fuck,” I heard someone whisper. After nearly thirty minutes the doctor stood
up. “Let’s call it.” The bustling stopped. A nurse’s voice floated above the whirring
and beeping of machines, “You want me to hold the epi, then? Okay, we’re calling it. Everyone, time of death: one twenty-three.” We all stripped off our gowns and filed out
of the room, quietly.

Out of the corner of my eye, I
could see where my patient’s body lay beyond the glass pane—motionless under
the glow of the examination light I had forgotten to turn off. My resident stepped into the room, took a
cursory look, then popped back out. “It
looks good, man.” I smiled and thanked
him. It seemed strange accepting a
compliment for placing stitches in a dead man.
But before I could mull it over, two women led by a nurse entered the
ICU.

One was older, and the other
much younger—maybe a mother and a sister.
I couldn’t be sure. The nurse led
them to the room’s entrance, slid the glass door open just wide enough, and
whispered something inaudible. The
guests nodded and the nurse stepped away, leaving them alone. I eyed the older woman as she paused at the
doorway. The younger one—she must have
been the daughter—took her mother’s hand and together they stepped into the
room. Both paused a few feet from the
bed. Then deliberately, the sister
glided right up to the bedside and slipped her hand over his. I watched her tremble and for a moment I
tried to focus my gaze elsewhere. Then
the sister lowered her face into the man’s shoulder and began to sob. This time, I looked down at my keyboard and
didn’t look back for some time. But I
could hear her faint whimper through the opening in the glass door.

Thursday 2:10 a.m. I was slouched in front of a computer in the
ICU. My fingers scampered in syncopated
bursts across a keyboard and underneath the weight of my eyelids, the ICU faded
out… then in… then back out again.
Through this sweet haze of thinly formed sleep, I heard the approaching
footsteps of my resident. “You want to
close the thoracotomy?” The fluorescent
lights of the unit rushed back into focus.
“Yeah, I’ll do it,” I heard myself respond. It was almost a reflex. I had never closed a thoracotomy before, but
as a student, I wasn’t in the habit of passing up such opportunities. “Okay, everything you need is already in the
room when you’re ready. Let me know if
you need help or anything, but it’s pretty simple. I mean, it’s just got to stay closed. Don’t worry about making it pretty, you know.” He picked up a chart and continued walking.

The exam light remained
illuminated in the dim room, its single beam never wavering from the wound that
I had closed. Even as family members
mourned in the darkness, I could see every insignificant detail of my suture
gleaming from behind the glass. Under
the spotlight, the wound seemed to glow as some strange memento of our hollow
impact. All our efforts had amounted to
essentially nothing. And as officials
from the coroner’s office sealed the body bag, I held in my head images of his
dropping blood pressure, his frenzied surgery, the rosy color of his lung, and
the numbers on the clock when we pronounced him dead. These things I knew, but really I knew
nothing. I knew nothing of how a story
of thirty years had unfolded. Or what
thread held together the chapters of a life I had watched unravel in a few dark
hours. I was only there to place the
last few stitches, and stand in the shadows as fresh wounds opened in the lives of those who knew
enough to mourn.

Eventually, the night faded into
nothing, and with it our empty efforts.
Yet all the details remained imprinted in my mind as a reminder of
medicine’s harsh reality. I’ve been
lucky enough to stand alongside heroes who pour their hearts and minds into
providing some small amount of healing where it is needed most. I’ve seen them labor and sometimes limp in
their efforts to create some meaningful impact in the lives that intersect with
their own. All the while knowing that the
stakes are high and their best may in large part be forgettable. But they push forward in spite of this. If for no other reason than because it is
their singular privilege to do so.